A 65-year-old black woman with a history of hypertension, high cholesterol and diabetes mellitus is seen in follow up. She is currently on hydrochlorothiazide 25 mg daily, amlodipine 5 mg daily, lisinopril 20 mg daily, rosuvastatin 20 mg daily, and metformin 1000 mg bid.
Her blood pressure in clinic is 130/80 mm Hg, her BMI is 31 kg/m2 and her waist is 40 inches.
Recent labs show: total cholesterol 159 mg/dL, LDL-C 75 mg/dL, triglycerides 220 mg/dL, HDL-C 40 mg/dL, Hba1c 6.8%, and creatinine 1.3 mg/dL.
Her 10-year atherosclerotic cardiovascular disease [ASCVD] risk is calculated at 18.7%
The correct answer is: C. Icosapent ethyl 2 gm twice a day.
This patient is at high risk for future atherosclerotic cardiovascular disease (ASCVD) due to presence of diabetes, hypertension and high triglycerides despite reasonably well controlled LDL-C with a high intensity statin. Primary prevention patients with high cardiovascular risk can derive benefit from triglycerides lowering via icosapent ethyl esters. The Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (REDUCE-IT)1 trial recruited about 30% of primary prevention patients with diabetes with ≥1 additional risk factor for cardiovascular disease (CVD) (primary prevention cohort) which included age ≥ 55 years (men) or ≥ 65 years (women), hypertension, active smoker or quit within 3 months, HDL-C ≤ 40 (men) or ≤ 50 (women), hs-CRP > 3 mg/dL, creatinine clearance > 30 and < 60 mL/min, retinopathy, micro- or macro-albuminuria, or ABI < 0.9 without symptoms of claudication, similar to this case patient. Prescription strength omega-3-acid ethyl esters (option B) contain a combination of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). There are no large randomized trials that have proven their use in cardiovascular risk reduction. The Vitamin D and Omega-3 Trial (VITAL) trial showed that supplementation with omega-3 fatty acid at a dose of 1 g/day (options A and D) was not effective for primary prevention of cardiovascular events among healthy middle-aged men and women over 5 years of follow-up.2
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- Bhatt, DL, Steg G, Miller M, et al.. Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia. N Engl J Med 2019;380:11-22.
- Manson JE, Cook NR, Lee IM, et al. Marine n−3 Fatty Acids and Prevention of Cardiovascular Disease and Cancer. N Engl J Med 2019;380:23-32.